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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> SITE MITIGATION MASTERFILE RECORD FORM <br /> GENERAL PROGRAM FILE: New V Change Edit (PROG4) revised 5/23/94 <br /> FACILITY ID # FACILITY NAME u <br /> JC O ` L/��6)/ f f 7.f /� C <br /> RECORD ID # PRIOR DIST # /`r PRIIOR SWEEPS <br /> Site Mitigation: Environmental Assessment ST/CAP Local Hazardous Waste Invest zMat Pipeline Invest <br /> Other Lead Agency Site ( envy: WQCB DTSC EPA L Site �ater Quality Site I Jt-h-r Type Site <br /> DESIGNATED EMPLOYEE # � PROGRAM ELEMENT # CURRENT STATUS <br /> NUMBER OF UNITS EPA ID INSPECTION CODE : <br /> Number of TANKS linked to this PROGRAM record : <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br /> PHS-EHD hourly charges associated with this facility or activity will be billed to the party identified as the BILLING PARTY on <br /> the Masterfile Record Information Form. <br /> I also certify that I have prepared this application and that the work to be perfo^ned will be done in accordance with all SAN <br /> JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal laws. <br /> r� <br /> APPLICANT'S SIGNATURE <br /> Title- Date: <br /> AUTHORIZATION TO RELEASE ION: In addition to the above, when applicable, I, the owner, operator or agent of same, of <br /> the property located atabove site address hereby authorize the release of any and all results, geotechnical data and/or <br /> environmental/site ass sment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br /> it is available and at the same time it is provided to me or my representative. <br /> DEADLINE DATES: Inspection: Current / / Prior <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> 2, 31 q 4 <br />